This questionnaire has been designed to give your therapist information as to how your back pain has affected your ability to manage in everyday life. Please answer every question by placing a mark in the box that best describes your condition today.

During the past 4 weeks......

Section 1 - Pain Intensity

Section 6 - Standing

I can tolerate the pain I have without having to use pain medication.

I can stand as long as I want without increased pain.

The pain is bad, but I can manage without having to take pain medication.

I can stand as long as I want but it increases my pain.

Pain medication provides me with complete relief from pain.

Pain prevents me from standing for more than 1 hour.

Pain medication provides me with moderate relief from pain

Pain prevents me from standing for more than ½ an hour.

Pain medication provides me with little relief from pain

Pain prevents me from standing for more than 10 minutes.

Pain medication has no effect on my pain

Pain prevents me from standing at all.

Section 2 - Personal Care (e.g., Washing, Dressing)

Section 7 - Sleeping

I can take care of myself normally without causing increased pain.

My sleep is never disturbed by pain.

I can take care of myself normally, but it increases my pain.

I can sleep well only using pain medication.

It is painful to take care of myself, and I am slow and careful.

Even when I take medication, I sleep less than 6 hours.

I need help, but I am able to manage most of my personal care.

Even when I take medication, I sleep less than 4 hours.

I need help every day in most aspects of my care.

Even when I take medication, I sleep less than 2 hours.

I do not get dressed, I wash with difficulty, and stay in bed.

Pain prevents me from sleeping at all.

Section 3 - Lifting

Section 8 - Social Life

I can lift heavy weights without increased pain.

My social life is normal and does not increase my pain.

I can lift heavy weights, but it causes increased pain.

My social life is normal, but it increases my level of pain.

Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned (e.g., on a table).